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ALTITUDE-ITS EFFECTS UPON DIFFERENT INDIVIDUALS, WITH REPORT OF TWO CASES.*

By GEORGE S. Gove, M. D., Whitefield, N. H.

Some months ago, I was requested by your honorable executive committee, to contribute a paper that should be presented at this meeting. The subject was left optional to me.

For the past four and one-half years I have been enrolled with the invalid corps, and within that time I have met with no case in my limited general practice which would be of special interest to you, but while journeying through California in 1889-'91, there came under my observation two cases of particular interest to me, and I have decided to make a brief report of these cases the subject of my paper, hoping some useful deductions may be drawn from their consideration.

Our route was over the Santa Fe. I had a time-table which also gave the elevation of the most important stations, several being of very high altitude.

Noticing this and also that the rise to all of these is so gradual that one would be scarcely conscious of it, the less so as the railway winds along in apparent valleys with high mountains all about (it being the same when at the highest points), it occurred to me to observe the effect of these high altitudes upon different members of the party.

There were between forty and fifty of us, varying in age from the infant to those who were upwards of eighty, and, all being strangers to me, they furnished an exceptionally good field for study.

At Raton Pass, near the eastern boundary of New Mexico, we reached an elevation of something over 7,600 feet. As we ascended to this, I noticed that some of the children were very restless, calling more frequently for water, while others showed no physical disturbance. What was true of the little ones was true of others regardless of age. There was one person who was making a good deal of effort in breathing. She was using her fan vigorously and her countenance gave evidence of great suffering for the want of air. We were detained at this pass for a short time, but as we descended her discomfort became proportionately less.

* Read before the New Hampshire State Medical Society, September 24, 1896.

Three more high points were to be overcome: Glorietta Pass with an altitude of 8,432 feet; the Continental Divide, 7,295 feet (these in New Mexico); and Flag-Staff in Arizona, 6,933 feet. We made no stop at any of these, but at each of these localities the lady gave the same evidence of distress as at Raton Pass, and while at Glorietta Pass I was called on to prescribe for her. I administered stimulants and heart tonics which served to tide her over the difficulty until the descent could be made, and she required my services no more during the journey.

Meantime, I learned that some time previous to the journey this lady had passed through a severe illness, which was diagnosed by her family physician as pneumonia. This was followed by a troublesome cough and dyspnoea; for the relief of this she was advised by her physician to spend the winter months in California. After reaching Pasadena, I saw no more of her until about the first of April, when she made her appearance at the Raymond. Hotel, where I was boarding. It was upon the eve of her setting out on her homeward journey. In conversation with her I learned that she was disappointed in that she had not gotten the relief from the journey and change of climate that she had been led to expect, and certainly her appearance confirmed her opinion.

I was to return to the East with the same party of which she was a member. We left Los Angeles in the morning and nothing occurred during the day to mar the peace and delight of the journey until along in the night I was called by the conductor to see a lady in another part of the car. On reaching her berth I found the patient to be the same one of whom I have written. She was suffering as she had on previous occasions when making the Passes, only her sufferings were much intensified, so much so that nothing done for her seemed to bring relief; that only came to her as we made the descent from Flag-Staff, when she was again comfortable until we approached the Continental Divide, when the distressing symptoms again returned and her struggle for air was hard to witness; it was only by the greatest exertion that her life was preserved to pass this elevation.

Because she had overcome so much we hoped that she would succeed in withstanding the effects of the higher altitude to be encountered at Glorietta Pass, but when we commenced the ascent to this point she had not fully recovered from the depressing effects of the last attack and soon began to show signs of increased physical disturbance.

The elevation at the summit of this Pass is 8,432 feet, and for a long distance before reaching it the rise is very gradual so that the degree of discomfort attending the high altitude was much prolonged; this she was unable to endure, and just as we reached the summit she struggled in vain for breath and passed away.

This brings me to a case that I was called to treat while in California during the winter of 1891. The patient was a young Canadian, twenty years of age, a domestic in the Raymond Hotel, Pasadena. This young woman, previously healthy excepting 'for occasional attacks of asthma, had spent an afternoon at the beach, and had passed an hour and a half bathing in the surf and frolicking upon the beach. Late in the evening of the second day after this I was called in to see her professionally. I found her with a high fever, severe headache, labored respiration, and a troublesome cough. I gave her remedies and left orders to be called if these did not bring relief. Early in the morning of the third day I was called to her again. I found the patient laboring for breath, face purple, pulse too rapid to be counted, and plenty of moist rales in both lungs. I was tempted to take blood from the arm, but, being a tramp physician in the State, decided to call counsel.

Dr. D. B. Van Slack, of Pasadena, a worthy gentleman and physian, formerly from near Boston, Mass., was summoned to meet me and responded at once. On his arrival he inspected the patient, who by this time had become delirious and was muttering and coughing constantly. After a hurried consultation, we decided that as the patient was in a critical condition, requiring something to be done at once to relieve the over-burdened heart and lungs, it was best to adopt heroic measures. We opened a vein. At first the blood merely dribbled from it, but by rousing her and using considerable effort in friction, we succeeded in taking a pint of exceedingly dark blood. For a few minutes after the vein was closed we thought the patient would expire, but in about ten minutes there was a change for the better in her circulation, her condition improved so much that in an hour she had become conscious, her respiration was less labored and her face less congested. It was arranged that Dr. Van Slack should meet me again in the evening, but before then I found that the patient was fast relapsing into the condition of the early morning, so I telephoned him to come at once.

When he arrived we re-opened the vein and took from it from a pint to a pint and a half more of blood. Before the vein was

closed there was a perceptible improvement in her condition; the heart-beats were stronger and less frequent, the respiration easier and the face of more natural color. From that hour she continued to improve, going through with double pneumonia with but little suffering, and making a good recovery with no perceptible bad effects from either the disease or the treatment.

The prevailing antipathy to venesection among the people, and also with the greater number of my medical brethren, has often restrained me from resorting to it.

I have been an advocate of it in the early stages of pneumonia, and pleuro-pneumonia, and in reviewing my history of these cases, I find no cause for regret for having resorted to this practice, but I have regretted that I had not employed this means for relief, as my judgment dictated, when my efforts by other methods proved of no avail.

In the history of the two cases given you there was a similarity of conditions, viz., labored respiration, rapid pulse, puffed and congested face, distended veins, and the early maturing of delirium.

The results in the second case were undeniably due to the bloodletting, which relieved the burdened heart and lungs. I was debarred by circumstances from pursuing the same method in the other case, but might not the unhappy termination have been averted could I have done so?

In an address upon "The Special Influence of Altitude upon Health, Disease and Sanitation," Dr. S. E. Solly, of Colorado Springs, who for several years has made a study of this subject,

says:

"When air is inhaled into the lungs, a certain proportion of the total amount of oxygen contained in this air is absorbed by the hemoglobin, which is that element of the blood which is contained in the red corpuscles, and whose business it is to absorb oxygen. As each drop of hemoglobin can only take up oxygen in certain proportion to the oxygen pressure of the air, when the oxygen pressure is lowered, as it is in the elevated climates, discomfort ensues to the visitor, because his blood is not sufficiently oxygenated at each ordinary breath. To remedy this he breathes faster, so as to get in more air, and so more oxygen, in a given space of time, and the heart has therefore to pump blood more irequently into the lungs and his pulse beats faster. Such is the temporary remedy, but in time the chest becomes expanded so

that more air is taken in at each breath and the heart is stretched; thus its cavities hold more blood and its walls are thickened, so that the muscle has more force to pump this increased amount of blood

"Nature's method of compensating for this deficiency does not stop here, however, and a still more remarkable change takes place and one in which lies the special therapeutic value of high climate for appropriate cases. This change is the increase in the amount of red corpuscles and hemoglobin; by this the oxygenabsorbing power of the blood is largely fortified in a definite ratio. to the elevation."

Experimenters in South and Central America, as well as in the high altitudes of the United States, have done a great deal of work and been able to confute many of the wrong conclusions drawn by the great traveler and scientist, Von Humboldt. These men found that there was a decided increase of certain normal constituents of the blood in a few days, and that many times health and strength followed as a natural sequence. They seemed to establish the following facts, namely:

"That the peculiar effects of high climates are to increase the amount of red corpuscles, hemoglobin, and the power of blood absorption. The chest expansion is also increased, the latter being admitted by all observers, who also have remarked frequently upon the almost emphysematous character of the breathing, especially at the apices of the lungs of the native-born children and old residents.

"With regard to the assumed enlargement of the heart cavities. and muscle, no sufficiently precise or extensive experiments have been as yet made to prove what logical deduction and common belief endorse, viz.: physiological cardiac hypertrophy. The remarkable powers of horses raised in high climates to endure prolonged fatigue and great speed, both in their native uplands and also when transferred to the sea level, are matters of common observation and belief. In men, the superior endurance of mountain eers, is also well known. This has been noted especially by Hirsch, in accounting for the endurance of the natives, resident in the high Andes. Further, the results of the treatment of heart disease by the strengthening effect of climbing and high climates, as recommended by Oertel, tend to confirm the belief that the heart is increased both in strength and capacity by altitude. We have then as the special physiological effects of altitude, that is, of diminished

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